Medicare Part D, or prescription drug coverage, is a federal government program that helps seniors and people with disabilities pay for prescription drugs. Part D provides a variety of benefits that are designed to make it easier and more affordable for people to get the medications they need. However, there are certain drugs and treatments that are not covered by Part D. In this blog, we will take a closer look at what other drugs Medicare Part D does not cover, including vitamins and other types of drugs.
Understanding Medicare Part D Coverage
Medicare Part D is a prescription drug plan that provides coverage for medications that are prescribed by a doctor. It is available to people who are enrolled in Medicare, including those who have Original Medicare, Medicare Advantage plans, or other Medicare health plans, and it has a monthly premium, which in 2023 is around $43. Part D plans are sold by private insurance companies, which means that the specific benefits and costs of each plan can vary.
Medicare Part D coverage is divided into several phases, each with different cost-sharing requirements. During the initial coverage phase, beneficiaries pay a deductible (if their plan has one) and a copayment or coinsurance for each prescription. Once the total drug costs for the year reach a certain threshold, the beneficiary enters the coverage gap or “donut hole” phase, where they are responsible for a larger portion of their medication costs. In 2023, the threshold for entering the coverage gap is $4,350 in total drug costs. Once the beneficiary has spent a certain amount of money out of pocket, they enter the catastrophic coverage phase, where their costs are significantly reduced.
Part D Drug Tiers
Medicare Part D drug tiers refer to the different levels of cost-sharing that beneficiaries are responsible for based on the category of the medication. Part D plans are using a tiered system to help determine the cost of the medications they cover. There are typically four or five tiers, and each tier has a different cost-sharing requirement.
The first tier is usually the lowest-cost tier and includes generic medications. These medications typically have the lowest copayments or coinsurance amounts. The second tier includes preferred brand-name drugs, which are medications that have been identified by the Part D plan as being more cost-effective than other brand-name drugs in the same category. These medications may have a slightly higher cost-sharing requirement than generic medications but are still typically less expensive drugs than non-preferred brand-name prescription drugs.
The third tier includes non-preferred brand-name drugs. These medications are usually more expensive than preferred brand-name drugs and may have higher copayments or coinsurance amounts. The fourth tier includes specialty drugs, which are medications that are used to treat complex or chronic medical conditions, such as cancer or rheumatoid arthritis. These drugs are typically the most expensive and may have the highest copayments or coinsurance amounts.
Some Part D plans may also have a fifth tier, which includes certain high-cost medications that are not covered by the first four tiers. These medications may have very high copayments or coinsurance amounts, and beneficiaries may need to meet additional requirements to get coverage for them.
To illustrate how the tier system works, here are a couple of examples. Let’s say that a beneficiary needs a prescription for blood pressure medication. If the medication is a generic drug, it will likely be in the first tier, which means the beneficiary will only have to pay a small copayment or coinsurance amount. However, if the medication is a non-preferred brand-name drug, it may be in the third tier, which means the beneficiary may have a higher copayment or coinsurance amount.
Now let’s say that the beneficiary needs a prescription for a specialty drug to treat cancer. If the drug is in the fourth tier, it may have a very high copayment or coinsurance amount. Some Part D plans may require beneficiaries to meet certain criteria, such as prior authorization or step therapy before they will cover a specialty drug. This means that the beneficiary may need to try other medications before the Part D plan will cover the specialty drug.
What Drugs Are Not Covered by Medicare Part D?
While Medicare Part D provides coverage for many prescription drugs, there are some types of medications and treatments that are not covered. These include:
- Over-the-Counter Medications – Part D does not cover over-the-counter medications, such as aspirin, ibuprofen, or cold and flu remedies. These medications are typically available without a prescription and can be purchased at a pharmacy or grocery store. Some Medicare Advantage plans may offer coverage for certain over-the-counter medications, but this varies by plan.
- Vitamins and Minerals – Medicare Part D does not cover most vitamins and minerals, including multivitamins unless they are prescribed by a doctor to treat a specific medical condition. Some Medicare Advantage plans may offer coverage for certain vitamins and minerals, but this also varies by plan. It is important to note that even if a vitamin or mineral supplement is not covered by Part D, it may still be eligible for reimbursement under a flexible spending account or health savings account.
- Cosmetic Drugs – Part D does not cover cosmetic drugs, which are medications that are used for aesthetic purposes rather than for the treatment of a medical condition. Examples of cosmetic drugs include wrinkle creams and hair growth treatments.
- Weight Loss Drugs – Medicare Part D does not cover weight loss drugs, such as phentermine or orlistat, unless they are prescribed to treat a medical condition related to obesity, such as diabetes or high blood pressure.
- Fertility Drugs – Part D does not cover fertility drugs, such as Clomid or injectable gonadotropins, which are used to stimulate ovulation in women or improve sperm production in men. However, some Medicare Advantage plans may offer coverage for these types of drugs.
- Drugs for Erectile Dysfunction – Medicare Part D does not cover drugs for erectile dysfunction, such as Viagra or Cialis, unless they are prescribed to treat a medical condition, such as pulmonary arterial hypertension.
- Experimental Drugs – Part D does not cover experimental drugs, which are medications that have not yet been approved by the FDA for general use. However, in some cases, beneficiaries may be able to get access to experimental drugs through clinical trials or expanded access programs.
It is important to note that the list of drugs that are not covered by Medicare Part D may vary depending on the specific plan. Every Medicare Part D plan has a formulary – a list of drugs that the plan covers. It is important to review the formulary for any plan you are considering to ensure that it covers the medications you need.
In addition to the drugs listed above, there may be other treatments and therapies that are not covered by Medicare Part D. For example, some plans may not cover certain medical devices, such as nebulizers or insulin pumps. Some plans may also have restrictions on the frequency or duration of certain treatments, such as physical therapy or occupational therapy.
It is also important to note that even if a medication or treatment is not covered by Medicare Part D, there may be other options for getting assistance with the cost. For example, some drug manufacturers offer patient assistance programs that provide free or discounted medications to people who meet certain eligibility criteria. Additionally, some states offer prescription drug assistance programs that can help seniors and people with disabilities pay for their medications.
Final Thoughts
In conclusion, while Medicare Part D provides coverage for many prescription drugs, there are certain types of medications and treatments that are not covered. These include over-the-counter medications, vitamins and minerals (with some exceptions), cosmetic drugs, weight loss drugs, fertility drugs, drugs for erectile dysfunction, and experimental drugs. It is important to review the formulary for any Part D plan you are considering to ensure that it covers the medications you need. If a medication or treatment is not covered, there may be other options for getting assistance with the cost, such as patient assistance programs or state prescription drug assistance programs. Make sure to talk with a licensed insurance agent, like those at Jersey Insurance.
Craig W. Hansen is an insurance professional and co-founder of William & Michael Advisor Group LLC and Jersey Insurance Solutions. Craig has served his clients in many facets of the insurance industry, always with the same goal: excellence in service while building solid, long-term, lasting relationships. With over a decade of experience in the insurance benefits industry, Craig’s clients know they can call on him anytime and receive platinum service with a smile.
